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Research Paper
International Journal of
Pharmacy Practice
International Journal of Pharmacy Practice 2014, 22, pp. 407414

Exploring factors that contribute to dose administration aid

incidents and identifying quality improvement strategies:
the views of pharmacy and nursing staff
Julia F.-M. Gilmartin, Jennifer L. Marriott and Safeera Y. Hussainy
Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Vic., Australia

Keywords
community pharmacy; compliance aids;
delivery of care; elderly; interprofessional issues
Correspondence
Dr Safeera Y. Hussainy, Centre for Medicine
Use and Safety, Faculty of Pharmacy and
Pharmaceutical Sciences, Monash University,
381 Royal Parade, Parkville, Vic. 3052,
Australia.
E-mail: safeera.hussainy@monash.edu
Received February 27, 2013
Accepted October 17, 2013
doi: 10.1111/ijpp.12091
Abstract
Background Dose administration aids (DAAs) organise medicines that have been
repacked according to the day of the week and time of the day in which they must be
taken. In Australia, DAAs are commonly prepared by pharmacy staff for residential
aged care facility (RACF) medicine administration. Although the limited available
literature indicates that DAA incidents of inaccurate or unsuitable medicine repack-
ing do occur, there is a paucity of qualitative research identifying quality improve-
ment strategies for this service.
Objectives This study aims to investigate the perceived contributing factors to DAA
incidents and strategies for quality improvement in RACFs and pharmacies.
Methods Health professional perceptions were drawn from three structured focus
groups, including six pharmacists, five nurses, a pharmacy technician and a personal
care worker. Participants were involved in the preparation, supply or use of DAAs at
pharmacies or RACFs that were involved in a previous DAA audit. Transcripts were
analysed using thematic analysis.
Key findings Four major themes were identified as contributing to DAA incidents,
with quality improvement strategies aligned to those same four themes: communi-
cation, knowledge and awareness, medicine handling and attitude. Strategies
included improving interprofessional communication and addressing the limita-
tions associated with RACF medicine records; targeting medicine knowledge gaps
and increasing awareness of DAA incidents; encouraging greater care when prepar-
ing and checking DAAs; and fostering a team mentality among members of the aged
care team.
Conclusions Recommendations include using current findings to develop multi-
disciplinary quality improvement initiatives to prevent DAA incidents and to
improve the quality of this pharmacy medicine supply service.

Introduction
Residential aged care facilities (RACFs) provide accommoda-
tion and supportive services for older individuals who are not
able to live in their own homes. The large volume of medi-
cines used by their residents[13] are commonly managed via
dose administration aids (DAAs) in Australia.[4] DAAs
arrange medicines according to the day of the week and time
of the day in which they must be taken or administered.[5]
They may not be suitable for all medicines, including those in
the liquid form or those that require protection from mois-
ture, light and air.[6]
Community pharmacies commonly supply these devices
to Australian RACFs. The residents medication regimen
is used to guide the process of repacking medicines from
their original containers into the DAA. Blister pack DAAs
may be manually prepared by pharmacists and pharmacy
technicians, or via machines located at the pharmacy
or at a packing company. Sachet DAAs are only pre-
pared via automation. Without regard to the DAA pre-
paration method, the supplying pharmacist is responsible
for checking the accuracy and suitability of medicine

2014 Royal Pharmaceutical Society International Journal of Pharmacy Practice 2014, 22, pp. 407414
408
repacking within the final prepared DAA supplied to the
RACF.[7]
DAAs can reduce RACF medicine administration time,
have been perceived by staff as a safer method of administra-
tion compared with using original containers and may reduce
errors in administration.[8,9] Additionally, DAAs allow per-
sonal care workers (PCWs) to administer medicines in Aus-
tralian RACFs. PCWs are not required to undergo the
extensive medicine training required of nurses and make up
the majority of the Australian residential aged care work-
force.[10] It is in the public interest therefore that a high-
quality DAA medicine supply service is provided from
pharmacies to RACFs.
Studies have shown that there is the potential for medicines
to be inaccurately or unsuitably repacked into DAAs.[4,1114]
These DAA incidents have been previously defined as follows:
a discrepancy between the medicine record and the DAA;
unsuitable medicine repacking according to pharmaceutical
guidelines; damaged medicines; and inappropriately altered/
divided medicines.[11] A DAA incident encompasses both tra-
ditional errors such as medicine omission and quality
control issues associated with DAA medicine repacking, such
as the inclusion of moisture-sensitive medicines in the DAA
(unsuitable medicine repacking).[11] DAA incidents arising
from the preparation of DAAs and medicine administration
errors arising from the inaccurate use of DAAs are separate
sources of potential harm to the RACF resident.
Five studies, systematically identified from the literature,
have used audits to investigate the proportion of DAAs with a
DAA incident, prepared manually or via automation, and
found incident rates ranging from 3.1 to 11.5%.[4,1114]
These five studies have outlined some potential contribut-
ing factors and strategies to overcome DAA incidents.[4,1114]
Inadequate communication, especially between members
of the healthcare team, has been suggested as a contributing
factor.[4,12,14] Medicine records may be difficult to decipher
and the DAA preparation process can contribute to
inaccuracies if staff experience concentration lapses or
fatigue.[4,12,13]
Improved and more streamlined communication and col-
laboration between members of the regular (prescriber/
pharmacist/RACF staff) and occasional (hospital) healthcare
team can ensure that the prescribers intentions are clear and
they are accurately reflected in the medicines repacked into
DAAs.[4,12] Medicine records should undergo regular audit-
ing, updating and archiving of older versions, and both medi-
cine records and prescriptions may benefit from use of
standardised terminology and generic names for medi-
cines.[12,14] DAA preparation staff could be educated on the
consequences and significance of altering medicines, and
quality control processes (guidelines and standard operating
procedures) should be developed or improved in a collabora-
tive manner for DAA supply.[4,1114]
2014 Royal Pharmaceutical Society
Quality improvement for pharmacy medicine supply
Although these five studies examined DAAs for incidents,
presented overall DAA incident rates and outlined some
potential factors contributing to DAA incidents and strat-
egies for quality improvement, many of these contributing
factors and strategies appear to have been derived from
author perceptions and not through systematic and extensive
health professional consultation.
Aim
This article aims to explore health professional perceptions of
the factors contributing to DAA incidents and to identify
strategies for quality improvement.
Method
Focus groups involving aged care health professionals were
used to facilitate in-depth discussions concerning DAA
incidents.
Participants
Eligible participants included individuals who were involved
in the preparation, supply or use of DAAs for RACF medicine
administration. They had to work at pharmacies that sup-
plied DAAs to RACFs or at RACFs that used DAAs. Partici-
pants were sampled from 49 Victorian RACFs and their
affiliated pharmacies that were involved in a previous DAA
audit.[11] These individuals were likely to be informed on the
discussion topic and could provide practical advice for suc-
cessful quality improvement implementation in their work-
place. The investigators left approximately three recruitment
packs in communal meeting spaces at the pharmacies and
RACFs, and packs were handed to staff for themselves or for
other potentially interested participants. A letter of invita-
tion, explanatory statement and consent form were provided.
Furthermore, recruitment invitations and posters were sent
via email to staff contacts to pass onto others and place on
notice boards.
Ethical approval
Ethics approval was obtained from the Monash University
Human Research Ethics Committee.
Data collection
The focus groups were conducted between November 2011
and March 2012 and each session lasted between 100 and
120 min. They were held in the evening at Monash University,
Parkville, and were facilitated by a pharmacist who was a
member of the research team and had been involved in
a previous DAA audit.[11] The sessions were opened with
International Journal of Pharmacy Practice 2014, 22, pp. 407414
Julia F.-M. Gilmartin et al.
introduction and the focus group purpose, outline and
ground rules. A description of the previous DAA audit results
was provided, including the types and frequencies of identi-
fied DAA incidents.[11] A structured question guide was devel-
oped to facilitate focus group discussions and was assessed by
the research team for face and content validity. The focus
group questions were piloted with six postgraduate students
from Monash University, Parkville.
Participants were presented with brief factual descriptions
of seven different DAA incident types one at a time and asked
to outline factors that may contribute to their occurrence.
They were then asked to discuss quality improvement strat-
egies to prevent each of the presented incident types from
occurring. Participants were prompted to explain what they
or their workplace (either in the pharmacy or RACF) had
done, or should do, to address DAA incidents.
Data analysis
All focus group discussions were audiotaped and transcribed
verbatim. The data were analysed using thematic analysis fol-
lowing the framework approach. The themes were identified
as they emerged from the focus group transcriptions and
were managed using NVivo 9 (QSR International [Americas]
Inc., Cambridge, MA, USA). Identified themes were checked
across the entire data set and discussed among the research
team.
Results
Three structured focus groups were conducted with 13 health
professionals. Participants included six pharmacists, one
pharmacy technician, five registered nurses and one PCW.
The pharmacist and nurse focus groups were homogeneous,
whereas the third focus group was conducted with the PCW
and pharmacy technician.
The average length of time participants in each focus group
had worked with blister pack or sachet DAAs was 12 years
(pharmacists), 8 years (nurses) and 5.5 years (the PCW and
pharmacy technician). Three of the pharmacists, one nurse
and the pharmacy technician had worked with both blister
packs and sachets, whereas the remaining participants had
only worked with blister packs. The perceived contributing
factors to DAA incidents and strategies to reduce their occur-
rence are described below. These findings have been identi-
fied from the participant responses and include an analysis of
both what participants said and how they responded to the
discussion topics.
Perceived contributing factors to DAA
incidents and strategies for quality
improvement
The authors identified four main factors contributing to DAA
incidents from the participant discussions: communication,
2014 Royal Pharmaceutical Society
409
knowledge and awareness; medicine handling; and attitude.
Suggested strategies for quality improvement were aligned to
these same four themes.
Communication
Contributing factors
Pharmacy participants explained that RACF staff did not
communicate with them in a regular or timely manner when
DAA incidents were identified and medication regimen
changes occurred. They indicated that effective communica-
tion could be limited by language barriers at the RACF and
the multiple aged care contacts.
Some of them [PCWs] probably would not acknowl-
edge the error [DAA incident], they leave it for two,
three days and come and tell you this tablet is
missing. . . (Pharmacist 2)
The amount of mistakes [DAA incidents] we pick up is
incredible, just charts [medicine records] that arent
faxed [to the pharmacy]. (Pharmacist 5)
Pharmacy and nurse participants felt that prescriber commu-
nication was not optimal. Prescribers often did not provide
the pharmacy with medicine prescriptions in a timely
manner and may not notify RACF staff when visiting resi-
dents and changing medication regimens. Additionally, their
limited avenues for contact could prevent pharmacy staff
from efficiently querying medicine record ambiguities. It was
also noted that effective communication of medicine infor-
mation between RACFs and pharmacies could be limited by
technology failures, such as facsimile failure or poor quality
printing.
Both RACF and pharmacy participants felt that medicine
records may be unreliable and unclear. Inaccuracies may
result when new records replace older versions and hand-
written changes may be illegible. RACF medicine records may
be incomplete if medicine administration times are omitted
and records used in DAA preparation may not be updated to
reflect recent medication regimen changes.
Strategies
Pharmacy participants felt that communication with the
RACF could be facilitated by multidisciplinary meetings and
face-to-face information exchange. They felt that regular and
timely communication from RACF staff regarding medicine
record changes and DAA incidents was important. It was sug-
gested that whole medicine records should be faxed, instead
of portions, to allow for comprehensive communication.
RACF participants also recognised the importance of
following-up information transmitted via facsimile to the
pharmacy.
International Journal of Pharmacy Practice 2014, 22, pp. 407414
410
Pharmacy participants felt that communication with the
prescriber could be facilitated by accessing electronic medi-
cine records, influencing medication regimens following
medicine reviews and participating in direct communication.
Additionally, prescribers could be given direction to ensure
medicine management processes are accurately followed,
including notifying RACF staff upon resident visits.
So either he [the prescriber] needs to communicate
with the pharmacy or he needs to leave a note for the
staff [indicating] be alert . . . I have changed some-
thing [on the medicine record]. (Nurse 1)
Having doctors directly send changes and additions
straight to the pharmacy would make a huge differ-
ence. . . (Pharmacist 4)
It was suggested that pharmacy staff responsible for DAA
incidents should be notified, in a non-punitive way.
Any errors [DAA incidents] that they [pharmacists]
find . . . theyll . . . explain, this is what youve done
and thats part of the reason [why] they give them
[DAAs] back to the packers to fix, so they [are] fixing
their own mistakes, theyre aware of them. (Pharmacy
technician)
It was felt that medicine records should be updated in a timely
manner, and collaboration between health professionals
could allow for ambiguities to be clarified and information
omissions to be addressed.
Knowledge and awareness
Contributing factors
RACF participants identified that educational opportunities
covering medicine handling issues, such as medicine identifi-
cation, may not be regularly offered or attended by staff. Par-
ticipants showed a lack of awareness regarding the different
types of DAA incidents that can occur and indicated that their
colleagues may not be aware of the frequency of DAA inci-
dents that occurred in their workplace. Additionally, RACF
and pharmacy participants showed deficiencies in their
understanding of DAA preparation and medicine adminis-
tration processes respectively.
Its interesting actually that we have our mandatory fire
training [and] our mandatory physical handling of
residents, but we dont have mandatory pharmacy
issue training each year. . . (Nurse 1)
Pharmacy participants identified that the replacement of
nurses with PCWs for medicine administration restricted
their ability to supply unstable medicines in their original
containers. It was also noted that PCWs may not be able to
identify medicines upon administration.
2014 Royal Pharmaceutical Society
Quality improvement for pharmacy medicine supply
Its a little bit scary that people can give out medica-
tions and have no idea [about what theyre administer-
ing]. . . (Pharmacy technician)
Strategies
Pharmacy and RACF participants indicated that RACF medi-
cine administration could benefit from more qualified,
experienced and competent staff, with improved ability to
identify medicines and administer them from original con-
tainers. Additionally, there should be greater awareness of the
types and frequencies of DAA incidents that occur.
We dont pack anything thats in the . . . guidelines
[outlining what should not be repacked into DAAs]
and we have a Div 1 [nurse] on the floor [at the RACF]
and they have to give out all the non-packed stuff . . .
(Pharmacist 6)
The whole thing is education . . . [its] pointing out
that these are your common errors [DAA incidents], so
educating people of what the errors are, so that theyre
aware of them, so they can try and make sure they dont
happen. . . (Pharmacy technician)
RACF medicine education should be offered regularly and
frequently and should be followed up and reinforced with
assessment. It was suggested that staff attendance can be
facilitated via mandatory, remunerated sessions offered at
different times.
Nurse educators inside the facility, where theres a Div
1 [nurse] training the PCAs [PCWs] regularly, that
seems to make a big difference. (Pharmacist 4)
Medicine handling
Contributing factors
The DAA preparation process at the pharmacy was identified
as a source of DAA incidents. DAA incidents could arise from
failing to incorporate recent medication regimen changes
into the DAA; inattention to detail when handling medicines
or interpreting medicine records; or deviating from DAA
preparation systems. It was noted that difficulties could arise
when preparing large volumes of DAAs, working within strict
time constraints and handling small tablets. Pharmacy par-
ticipants did not believe DAA preparation guidelines were
comprehensive, clear, practical and effective at preventing
incidents.
Where the packers [DAA preparation staff] dont
follow the system, thats when all the errors [DAA inci-
dents] come. . . (Pharmacist 4)
International Journal of Pharmacy Practice 2014, 22, pp. 407414
Julia F.-M. Gilmartin et al.
RACF participants explained the difficulty associated with
identifying medicines following brand changes or when
medicines lacked distinguishing features and pharmacy par-
ticipants felt it was difficult to check DAAs where multiple
medicines were repacked together. Instances where RACF
staff did not check medicine records prior to administration
were described and where PCWs, rather than nurses, were
responsible for checking DAAs that had been delivered to the
RACF. Participants also identified human error as a contrib-
uting factor to DAA incidents in general or to specific inci-
dents such as incorrect medicine strength, incorrect form or
quantity, and medicine omission.
There is an issue I have noticed on occasions where
staff dont sign off their medication charts until after
theyve done their [medication] round and also I was
watching somebody one day and she doesnt read her
medication charts first, she trusts the blister pack, she
trusts the sachets [when administering medicines].
(Nurse 1)
Pharmacy participants expressed frustration at financial
pressures that impacted on their service provision. Untimely
prescription supply from prescribers and government medi-
cine cost-cutting initiatives restricted profitability, as well as
inadequate remuneration for their DAA supply service.
More training costs money, more checking costs
money as much as it really needs to be a hundred per
cent right all the time, they dont want to put more
people on [staff at the pharmacy]. (Pharmacy
technician)
Strategies
DAA preparation could be improved with clear and simple
guidelines that outline pharmacy staff roles; processes that
protect medicine integrity, such as keeping medicines within
their original foil and packing these protected medicines into
DAAs and not overfilling individual DAA compartments; not
preparing DAAs too far in advance; prescribing medicines
with improved stability for DAA repacking; rewriting
unusual dose schedules into clearer formats; and attention to
detail when handling tablets. DAA labels may benefit from
pictures of medicines, names and descriptions.
DAA checking at RACFs can benefit from regular staff who
are familiar with resident medication regimens, increased
staff volume or shared workloads, minimal brand changes
and tablets with distinguishing features. DAA checking could
be incorporated into routine practice and stipulated as a nec-
essary staff duty. A greater level of checking should be under-
taken, rather than simply counting tablets, and irregularities
should be queried and addressed. It was also noted that all
individuals involved in medicine handling at the pharmacy
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and RACF should be involved in DAA checking, not just the
pharmacist.
You need multiple people checking [DAAs] . . . the
original pharmacist and then the RNs [nurse] and then
maybe the staff giving it [administering medicines].
Everybody just needs to be vigilant. (Nurse 1)
If youve got medication competent people . . . [under-
taking] medication administration, they know the resi-
dents theyve become very familiar with . . . what
theyre taking . . . and then they will become more
familiar with the appearance of those medications and
be more aware . . . if there are packaging errors [DAA
incidents]. . . (Nurse 1)
Participants indicated that DAA incident accountability at
the pharmacy could be improved by ensuring staff sign for the
DAAs they prepare and by recording the names of staff
involved in DAA incidents. Workplace tasks could be rotated
if staff are involved in DAA incidents or to prevent compla-
cency during repetitive DAA preparation processes.
We have an error policy . . . if they start making too
many errors [DAA incidents] then they have to go and
do something else or they have to recheck their packs
[DAAs] twice. . . (Pharmacist 6)
Participants outlined that RACF quality improvement
initiatives could be developed and implemented via staff
consultation, explaining the importance of initiatives to
staff and providing education regarding the initiative. Addi-
tionally, pharmacy participants identified that pharmacy
profitability associated with their DAA supply could be
improved with government initiatives that recognise medi-
cine records as prescriptions and with adequate financial
remuneration.
Attitude
Contributing factors
When discussing DAA incidents, the participant responses
were often dismissive, defensive or defeated. It was not uni-
versally acknowledged that DAA incidents occurred to a sig-
nificant extent in the workplace and some participants
indicated that they had not seen certain incidents at all or had
seen them rarely, such as incorrect tablet halving or medicine
omission. Pharmacy participants felt that it was impossible to
prevent all DAA incidents as in many cases minimal viable
strategies existed to address them. Some also expressed the
feeling that as long as the resident was receiving his/her medi-
cine, then the incident was not an important consideration.
Some RACF participants felt that incidents in general were of
minimal importance compared to other workplace issues,
International Journal of Pharmacy Practice 2014, 22, pp. 407414
412
such as instances where the pharmacy had not been able to
deliver medicines to the RACF in the evening.
I mean some of these things [DAA incidents] are quite
minor, compared to people just not getting their medi-
cines. (Pharmacist 4)
Using the excuses of limited staff resources, time and remu-
neration, some pharmacy and RACF participants showed
little motivation towards DAA checking and outlined how
their colleagues viewed this activity in a negative light. RACF
participants felt that their staff trusted DAAs to accurately
reflect the medicine records, whereas DAA preparation staff
sometimes placed the responsibility of DAA checking and
incidents onto the pharmacist.
I was just going to say its a big job . . . when the new
packs [DAAs] come up [from the pharmacy], you
verify [check] them, but then thats just repeating work
that I think we shouldnt really be doing. (Nurse 2)
Participants indicated that interprofessional relationships
were strained both in general and as a result of interactions
directly related to DAA service provision. Prescribers often
needed constant direction to ensure medicine supply
occurred in a timely and efficient manner. In some cases
pharmacy participants queried the competence of medicine
administration staff and described unfavourable pharmacy
workplace conditions for their own staff, including poor
wages. Additionally, they felt restricted in their professional
autonomy when directed to repack unstable medicines into
DAAs to facilitate PCW medicine administration.
Yeah I check mine [DAAs with RACF medicine
records] once a month, regularly, I think were legally
obliged to do 10% every three months . . . but we do
more than that, if I did that, half the people would be
dead, honestly. (Pharmacist 5)
Sometimes I feel like were . . . two different worlds
apart and youll ring a facility [RACF] and they just
wont have [the] time or understanding for the phar-
macy. . . (Pharmacy technician)
Strategies
RACF participants felt that working collaboratively with
other health professionals to prevent DAA incidents was
important and they acknowledged the importance of their
healthcare role. Some participants accepted responsibility for
their own learning, felt motivated to attend educational
opportunities and appreciated the limitations of their current
knowledge.
Be aware that other people make errors just as we do,
therefore you need to be part of the team and part of
the [DAA] checking process. (Nurse 1)
2014 Royal Pharmaceutical Society
Quality improvement for pharmacy medicine supply
Pharmacy participants outlined strategies to improve rela-
tionships with the RACF. It was considered that all staff
should feel part of one team with a common goal. Relation-
ships may be improved with fewer RACFs serviced per
pharmacy, understanding RACF workplace difficulties and
acknowledging their quality improvement efforts. Identify-
ing relationship stressors, such as personality clashes, and rec-
tifying them via face-to-face contact or staff rotation was
proposed.
If you can somehow make them [RACF staff] feel like
you are with them, part of them, they seem to be more
helpful . . . you just have be really patient with them . . .
(Pharmacist 2)
Youre trying to have that personal contact [with
RACFs] and thats something that my pharmacy is
working on, sending people out to the homes [RACFs]
. . . to put names to faces and . . . build relationships . . .
something that . . . bridges the gap between the two.
(Pharmacy technician)
Discussion
Pharmacy and RACF health professionals perceived that
attention to medicine handling, both during DAA prepara-
tion and administration, increased staff knowledge and
awareness of workplace DAA issues, improved inter-
professional verbal and written communication regarding
medicines, and positive staff attitudes towards other health
professionals and their medicine management roles, may
reduce the likelihood of DAA incidents occurring and can
potentially improve the DAA service. This could be tested in
future work.
Study limitations were identified. Firstly, although partici-
pants were recruited in a way similar to the nurse and phar-
macist recruitment process, only one PCW and pharmacy
technician was involved in the third focus group. Their com-
ments were, however, largely congruent with the pharmacist-
only and nurse-only focus group findings, indicating that
greater variability in responses may not have been identified
with a larger group. Secondly, perceptions regarding DAA
incidents were not identified from prescribers involved in the
RACF aged care team as they have minimal involvement with
DAA preparation and use. Thirdly, quantitative research with
larger participant samples, using a survey, would be beneficial
to verify perceptions identified from these three focus groups.
Lastly, participant understanding of the factors contributing
to DAA incidents and strategies to address them could have
been influenced by a lack of personal experience of certain
DAA incidents.
Some of the factors contributing to pharmacy dispensing
errors identified in the literature and strategies for
quality improvement are similar to those identified in this
International Journal of Pharmacy Practice 2014, 22, pp. 407414
Julia F.-M. Gilmartin et al. 413

study.[15,1722] As DAA preparation is a form of pharmacy
dispensing, this may explain the similarity in findings.
However, this study is unique in that it examines the addi-
tional factor of communication between RACF and phar-
macy staff that may contribute to DAA incidents. Inefficient
communication within workplaces and between RACF and
pharmacy staff has been shown to potentially contribute to
medicine errors.[16,2325] In traditional pharmacy dispensing, it
is unlikely that this interprofessional interaction is present
and thus its influence on DAA incidents has not been exten-
sively explored in pharmacy dispensing error studies.
Factors contributing to errors in medicine administration
in RACFs are similar to those identified by the focus group
participants as contributing to DAA incidents. Common
medicine administration errors identified in RACFs have
included medicine omission, wrong dose, wrong administra-
tion technique and wrong time of administration.[2,2630]
Factors contributing to these errors included human error,
inaccurate medicine administration records, busy medicine
administration rounds and interruptions, heavy workloads,
limited familiarity with resident medication regimens,
limited knowledge regarding appropriate medicine adminis-
tration techniques, transcription errors and poor commu-
nication.[2,2630] The similarity in findings may relate to the fact
that medicine administration can also be considered a form
of medicine dispensing.
The focus group findings highlighted major quality
improvement strategies. Firstly, both prescribers and RACF
staff must recognise the pivotal role they play in ensuring
current medicine information is communicated to the phar-
macy to facilitate accurate DAA preparation. This is particu-
larly important as medication regimen changes often occur at
the RACF, although DAA preparation may occur offsite at the
pharmacy. Additionally, prescribers could be educated on the
importance of complete, accurate and legible records. Sec-
ondly, pharmacy and RACF staff could keep certain medi-
cines in their original containers for nurses to administer
from, thereby preventing unstable medicines from being
repacked into DAAs.
Thirdly, DAA checking should be regarded as a task that
must be undertaken by staff at both RACFs and pharmacies,
particularly as DAAs are often prepared at the pharmacy with
different medicine records to those which are held at the
RACF. Staff at both workplaces must check DAAs against their
own records to ensure that they have been prepared
accurately. Lastly, interprofessional strain between pharmacy
and RACF staff must be addressed to allow for close collabo-
ration and an efficient and accurate DAA supply service. Sug-
gested strategies to facilitate this include greater face-to-face
interaction and identifying and rectifying personality clashes
between staff members.
Conclusion
Consultations with health professionals involved in DAA
preparation, supply and administration identified a number
of contributing factors to DAA incidents that would benefit
from quality improvement, including communication, staff
knowledge and awareness, medicine handling and attitudes.
Strategies to reduce the occurrence of DAA incidents were
related to these factors and highlighted the importance of
quality improvement initiatives that are multidisciplinary
and multifactorial in nature. Further research is needed to
develop quality improvement strategies for pharmacy and
RACF implementation to improve the pharmacy DAA supply
service and RACF standard of care.
Declarations
Conflict of interest
The Author(s) declare(s) that they have no conflicts of inter-
est to disclose.
Funding
This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
Acknowledgements
The authors wish to thank Kerry Murphy and Souhiela Fakih
for taking notes during the focus groups.
Authors contributions
JFMG (70% contribution) drafted the initial manuscript and
revised it following significant input from SYH (15% contri-
bution) and JLM (15% contribution). All Authors state that
they had complete access to the study data that support the
publication.

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